GU Dysfunction

8/13/2019 GU Dysfunction

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Genitourinary Dysfunction

in Children



Pediatric Differences in theGU System:

• By age 1 year: kidneys function at adult level• Premature infants: glucose, sodium, bicarbonate,

phosphate reabsorption is decreased• Infant: only 20% of nephrons have Loops of Henlelong enough to reach medulla, thus cannotconcentrate urine as efficiently

• Bladder moves to pelvic cavity by early childhood• Children have shorter urethras predisposing them toUTI

• Achieve complete bladder control by 4-5 years of age



Urinary Tract Infection

• Prevalence: 5% in females, 1% in males

• Prevalence: Before age 6 months morecommon in uncircumcised males

• Can cause impaired renal function

• Unexplained fever: obtain urinalysis andurine culture



Etiology

• Bacteria ascending from the urethra into thebladder and to the upper urinary tract

• Escherichia coli : predominate organism• Candida rarely causes infection• Obstruction• Voiding dysfunction

• Constipation• Vesicoureteral Reflux (VUR)• Intercourse



Manifestations

• Often vague and nonspecific

• Fever: 100.4 or higher without evidence of

infection in children age 2-24 months• Irritability

• New or increased enuresis

• Dysuria

• Poor weight gain



Diagnostic Evaluation

• Urinalysis: hematuria, WBC’s, nitrites

• Urine culture: single-strain of bacteria in a clean

catch urine• Use a urine bag to collect sample

• Consider catheterization for sample

• May see a suprapubic aspiration for culture• Refrigerate urine if it is not processed within 10-15 minutes of collection



Nursing Management

• Obtain history including elimination patterns• VS: particular attention to blood pressure• Assess for CVA tenderness

• Assess for phimosis• Antibiotic instructions – 3-5 day course – Take single dose course at night – Prophylaxis in recurrent cases (VUR)

• Accurate I and O

• Encourage fluid intake (PO or IV)• Education regarding effects of untreated UTI in children• Review symptoms with caregiver• Follow-up diagnostic evaluation to confirm treatment efficacy• Additional education and evaluation for those who are sexually active



Cryptorchidism

• Undescended or hidden testes

• Begin descent at 26-28 weeks gestation• Premature infants have higher incidence

• Occurs in 5% of healthy full term males

• Etiology unknown



Associated Risks

• Most testes spontaneously descend withinthe first year of life

• If remains undescended: – Increased risk of malignancy

– Sperm production decreased

– Inguinal hernia more common



Nursing Interventions

• Assessment/Identification!!

– Assess in a warm environment

– Examine the older child sitting and in a frogleg position

– Milk the testis downward from the groin

– Assess for a hernia – Assess the abdomen




• Parental education/reassurance

• Review the risks of an undescended testes

• If surgically corrected, postoperative care

– Assess site

– Incentive spirometry

– Skin integrity

– Increase activity





Hypospadias and Epispadias

• Urethral meatus below or above normalplacement.

• Epispadias is rare• Hypospadias:

– 2/500 males

– Increased risk if father or sibling affected – Testes undescended in 10% of those affected

– Assess for stenosis



Manifestations

• Altered placement of urethral opening

• Altered urinary stream• Chordee (downward curvature of penis)

• Assess for obstruction of urine outflow



Therapeutic Management

• No circumcision

• Correction requires surgical intervention

• Done between 6-12 months of age (ideallybefore toilet training)

• Goal of surgery:

– Normalize urinary function – Normalize sexual function

– Cosmetic




• Identification through assessment

• Obtain history:

– Urinary tract infection

– Quality of urine stream

– Incontinence

– Family History




• Post-operative care:

– Pressure dressing for 4 days

– Stent or catheter for urine drainage – Hydration (IV the PO)

– Assess urine color, odor, clarity

– Monitor temperature

– Prophylactic antibiotics – Quiet, diversional play

– Pain management




• Extensive family education

• Restrict activity for 1-2 weeks

• Continued monitoring for UTI



Glomerulonephritis

• Inflammatory injury in the glomerulus

• Infection, Lupus, Schonlein-Henoch

purpura, vasculitis• Sudden onset, self-limiting, resolve

• Poststreptococcal is the most common



Pathophysiology

• Antigen-antibody complex formed

• Become trapped in the glomerulus

• Activation of inflammatory response

• Damage to capillary walls

• Decrease in GFR; renal insufficiency

• Large molecules are allowed to pass tourine



Incidence

• Group A beta-hemolytic streptococcalinfection (throat or skin)

• Young school age children• Higher incidence in winter and summer

• Symptoms appear 8-21 days after

infection



Manifestations

• Hematuria (smoky, tea colored urine)

• Edema (orbital, worse in a.m.)

• Decreased urinary output

• Hypertension



Relevant Laboratory Tests

• Proteinuria (mild)

• BUN and creatinine elevated in severe

renal insufficiency• Dilutional anemia

• C3 (serum complement) low

• Antistreptolysin (ASO) titer elevated (onlyuseful for recent infection where the childhas not received antibiotics)



Nursing Management

• Strict, accurate I and O (hourly)

• Report oliguria

• Accurate daily weights

• Monitor for hypertension• Antihypertensive medication if necessary

• Astute respiratory assessment

• Fluid restriction (monitor for signs of dehydration)

• Low-sodium diet• Cluster care to provide rest

• Reassurance the illness is self-limiting



Nephrotic Syndrome

• Primary (MCNS): most common

• Secondary: acquired from systemic

disease (lupus, hepatitis, cancer)• Arises from one of 4 types of renal lesions

which all affect the basement membrane

of the glomerulus



Incidence:

• Children ages 2-6 years

• Slightly higher in boys

• Prognosis for MCNS is good

• Symptoms decrease with age



Pathophysiology

• Insult to glomerular basement membrane

• Increased permeability resulting in loss of

plasma proteins• Fluid shift to interstitial space

• Hypovolemia and decreased renal blood flow

•Renin production stimulated

• Reabsorption of sodium and water

• Edema



Pathophysiology (cont’d)

• IgG levels decreased

• Cholesterol and triglycerides elevated

• Hypercoagulable



Manifestations

• Proteinuria* (frothy urine)

• Hypoalbuminemia*

• Edema* (orbital, worse during day)

• Normotensive

• Increased weight

• Respiratory infection

• Abdominal pain (fluid in peritoneal space)





Diagnostic Evaluation

• 3+ - 4+ urine protein

• Dark, frothy urine

• Decreased serum albumin• Increased Hgb and Hct

• Increased serum cholesterol

• Increased serum triglycerides• Negative ASO

• Evaluate for underlying etiology



Management

• Prednisone

• Diuretics

• Albumin

• Antibiotics

• No-added-salt diet




• Assess VS (hypovolemia)

• Strict I and O

• Assess for dehydration

• Daily weights• Assess exposure to communicable disease

• Prophylactic Penicillin

• Follow labs closely (risk of venous thrombus)

• Measure abdominal girth• Astute assessment of pulmonary status

• No salt added diet

• Consider fluid restriction if becomes hypervolemic



Acute Renal Failure

• Sudden, severe loss of kidney function

• Prerenal causes: dehydration,

hypotension, shock, renal arteryobstruction, aminoglycosides, contrast dye

• Postrenal causes: structural abnormalities(tumor, ureterovesical obstruction,

neurogenic bladder)• Rare in children



Manifestations

• Electrolyte and fluid imbalance

• Increased BUN and creatinine

• Acid-base imbalance (acidosis)

• Oliguria (urine output <1cc/kg/hr)

• Poor feeding

• Lethargy

• Seizures



Hemolytic Uremic Syndrome asa cause of ARF

• Most common cause of acute renal failure

• Shiga’s E-coli

• Causes an inflammatory process• Anemia

• Thrombocytopenia

• Acute renal failure• Source: improperly cooked meat and

contaminated dairy



Laboratory Data in ARF

• Azotemia (elevated BUN, creatinine, anduric acid)

• Metabolic acidosis (low serumbicarbonate)

• Increased potassium

• Increased or decreased sodium



Nursing Goals

• Monitoring and maintaining fluid andelectrolyte balance

• Prevention of Infection• Adequate nutrition

• Parental education (decreasing parent an

child anxiety)



Chronic Renal Failure

•Irreversible loss of kidney function

• Progresses to end stage renal disease

• Common cause: congenital anomaly

• Rare in children (18/1 million)



Manifestations

• All associated with acute renal failure

• Renal bone disease

• Poor growth (FTT)

• Chronic hypertension

• Neurologic symptoms



Nursing Goals

• Adequate nutrition

– Na and fluid restriction

– Protein restriction – Potassium restriction

– Phosphorus restriction

– Vitamin D – High calorie foods



Nursing Goals

• Prevention of infection

• Skin integrity

• Family education

• Developmental activites based on child’sage

• Multidisciplinary approach





The End

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GU Dysfunction